3 Part Minor Release Form

SCA, Hero Of The Chalice , Dec. 29 , 2006, through Jan. 1, 2007
1915 Camp Florida Road, Brandon, Florida

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This form is intended for both youth attending with their parents/guardians and for youth attending with a responsible adult designated by the legal parent/guardian.  Sometimes, because of circumstances, it is not possible to reach the legal parent/guardian in a timely basis. Even if parents/guardians will be attending with their child, it is recommended that they complete all or at least part of this 3 part minor release form.
Child's Full Legal Name______________________________________________________ Age____ Birth Date _______
Grade ____ Child's E-Mail ______________________________  Child's cellphone  ______________________________

Other forms that might be required: Reservation and Combat

Emergency Medical Treatment Release:
I do hereby authorize that official trustees of SCA, Hero Of The Chalice are authorized to obtain emergency medical treatment for my child as necessary.  Photocopies of this release shall have the same force and effect as the original.
Parent/Guardian Printed Name________________________________________________________________________
Parent/Guardian Signature_________________________________________________________  Date _____________
Sworn to and subscribed before me this day of , in the year______________ State of  _____________________________
County of ________________________________  Signature of Notary Public  _________________________________
  Notary Seal:

 

 

   Commissioned Name of Notary Public    _______________________________
   Commission Expires   _________________________________

Parent/Guardian Release:
I, ________________________________________________________ (insert parent's full name) the parent/guardian of
________________________________________________________ (insert child's full name), a minor, hereby grant my child permission to participate and attend any and all activities associated with SCA, Hero Of The Chalice, except combat. My child/minor has permission to participate in on-site activities, including, but not limited to the following: meals, cabin bunkbed sleeping, showers, PG-13 movies, climbing, archery, and bicycling.  In giving this permission to my child to participate in the activities associated with this event, I realize that the risk of injury to my child resulting from participation in said activities is minimal but that risk cannot be completely eliminated. Therefore, I hereby release all participants of SCA, Hero Of The Chalice from any liabilities associated with my child's participation in said activities provided that such liabilities did not result from gross negligence during the course of said activities.  Photocopies of this release shall have the same force and effect as the original.

Parent(s)/Guardian(s) Emergency Contact Information
First and Last Name _______________________________________________________________________________
Home Phone_______________________ Work Phone________________________ Cell ________________________
Home Physical Address ____________________________________________________________________________
E-Mail _________________________________________________________________________________________
Family Doctor _____________________________________ Telephone: _____________________________________
Preferred Hospital: ________________________________________________________________________________
Child's Medical Insurance Company And Policy Number:   __________________________________________________ 
_______________________________________________________________________________________________
Health or Behavior Problems, including daily medication, allergies, and information about any medical condition or special problems the child might have. (attach note if more space needed)  ____________________________________________
_______________________________________________________________________________________________

Minor's Own Statement Of Understanding (If age applicable):

I, _____________________________ (child's signature if applicable) promise to follow all the rules of The State of Florida and the SCA.  The breaking of alcohol, drug, and other local laws will not be tolerated. Florida law makes it illegal for persons under the age of 18 to possess tobacco products and also illegal for anyone older to provide such items for them.  Parent(s)/guardian(s) may want to discuss additional rules with their child.  No destructive behavior or attitudes, fireworks, alcohol, sexual activity, tobacco or illegal drugs will be tolerated. No weapons that I do not have written SCA qualificaiton for. Minors must stay on site.  Leaving the premises requires written permission from Event Steward, Frances Mitchell
Circle One:  (Omnivorous) or (Vegetarian) or (Vegan)
Additional Rules Set By Parent(s)/Guardian(s):
On this line, I indicate for what activity(s) I do not give permission: ___________________________________________
______________________________________________________________________________________________